Beaufort-Jasper Eoc Head Start

Confidential Individualized Healthcare Plan

Child's Last Name:*
Child's Middle Name:
Child's First Name:*
What program option are you registering for?*

Center:*
Date of Birth:*
Parent/Guardian Name:*
Phone #:*
Parent/Guardian Name:
Phone #:
Parent/Guardian Name:
Phone #:

Healthcare Provider:
Phone #:
Preferred Hospital:
Emergency Contact:*
Relationship:
Phone #:
Current Health Issues:
Allergies:
History of Anaphylaxis:
Symptoms to give Epi-Pen:
Current Medications:
At Home:
At Center:

Asthma:
History-Acute or Chronic:
Current Medications:
At Home:
At Center:

Restrictions:
Relevant Activity/Diet:
Other Health Concerns:
Current Medications:
Other Pertinent Action Plans:

Medication will be furnished by parent/guardian in a container properly labeled by a pharmacist, and in the original container. All medications must have child's name, medication dispensed, dose prescribed and time it is to be given. I hereby give my permission for my child to receive medication during school hours. This medication has been prescribed by a licensed physician. I hereby release Beaufort Jasper EOC Head Start and their staff from all liability that may result from my child taking the prescribed medication. I give permission for the Beaufort Jasper Head Start Staff to communicate with the Medical Provider concerning diagnosed medical condition related to above prescribed medication.
I confirm that I have read and understand this form. *

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Parent Signature
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